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Acerca de

Marble Surface

MEDICAL HEALTH FORM

Name: _____________________________ DOB: _________ Phone Contact: _________________

Address: _______________________________________ Email: _______________________________

 

List any medications you have been taking in the past 6 months: _____________________ ____________________________________________________________________________________ Age: _______ Have you received chemotherapy or radiation in the past year? _________
Have you ever had an allergic reaction to any of the following (please circle):

Latex

Nitrile

Lanolin

Vaseline
Foods

Lidocaine

Alcohols

Paints


Have you ever had a cold sore?
If yes, contact your physician for a preventative prescription capsule to prevent a cold sore.


Are you currently taking medication that thins the blood? (fish oil/aspirin) Yes No


Are you currently under the care of a physician? If yes, please explain: ________________________ _________________________________________________Physicians Name: _____________________ 

 

Do you take antibiotics when going to the dentist? If yes, why_________________________________ 

 

Have you ever had one of the following (please circle):
Hair Loss

Anemia

Sensitivity to cosmetics

Prolonged bleeding
Trichotillomania

Epilepsy

Artificial Heart Valve

High Blood Pressure

HIV

Hepatitis

Liver Disease

Cancer

Keloid Scars

Fainting Spells
Alopecia

Healing Problems

Botox/Injections

Tumors, Growths, Cysts

Thyroid Disturbances

Medication

Metals

Crayons

Hair Dyes

Glycerin

Diabetes
Low Blood Pressure

Circulatory Problems

What would you most like to improve about your eyebrows? (Consider shape, color, density, thickness...) __________________________________________________________________________________

Please read the following statements carefully. 

 

Microblading is a way of cosmetic tattooing, intended to be semi-permanent lasting average 8-12 months. Procedure may be uncomfortable. Although extremely rare, there might be an immediate or delayed allergic reaction to the pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the first procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be performed if you are pregnant, nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are NOT followed correctly. There may be swelling or redness following the procedure. You may experience minor bleeding. If you have an MRI scan with your doctor 3 months after Microblading procedure, you should notify/discuss with your doctor. Possible scarring may occur.

I have received after care information and I am fully aware of the aftercare procedures. I fully understand the information provided above & confirm that all information provided by me is correct and truthful.

Client’s Name ___________________________ Signature_____________________________________ Date____________

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